role of the autopsy in medical malpractice cases, II: Controversy related to autopsy performance and reporting, The

Archives of Pathology & Laboratory Medicine,  Sep 2002  by Bove, Kevin E,  Iery, Clare

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Controversy Related to Autopsy Performance and Reporting

Context.-We studied 99 appellate court records in cases of alleged medical malpractice and found no relationship between discrepant clinical and autopsy findings and outcome of litigation. Standard-of-care issues and not diagnostic accuracy were at the heart of every case.

Objective.-To characterize and discuss issues related to the autopsy and/or pathologist behavior that were raised in court records of medical malpractice litigation.

Design.-In 18 appellate court records, issues were raised about quality of autopsy performance and reporting or about death certification. The details of these controversies are succinctly reported here in a manner intended

to be instructive to pathologists who perform autopsies in a hospital setting or on a private fee-for-service basis.

Conclusion.-Autopsy reports are intended to provide objective medical information in a coherent format to the patient's medical record, to the attending physician and other concerned staff physicians, to other health care professionals, and to the families of the deceased. Inevitably, occasions arise that require legal counsel to be added to this list of parties with a legitimate interest. Our findings emphasize that incomplete, incoherent, obfuscated, or delayed reporting of autopsy findings do not meet professional standards, are unethical if intentional, and may be counterproductive. (Arch Pathol Lab Med. 2002;126:1032-1035)

We reported in a separate article results of a study of 99 appellate court decisions to determine how autopsy results were used in medical malpractice litigation.1

We sought to determine whether there is a legitimate basis for fear among physicians that damaging information from autopsies will be introduced as evidence in malpractice lawsuits.2-4 The large discrepancy between the incidence of unexpected autopsy findings (54 [57/61 of 93 cases), and a court finding for the plaintiff (19 [19%] of 99 cases) indicates that factors other than autopsy findings are at the heart of a decision that malpractice has occurred. The purpose of this report is to present and discuss the implications of controversies related to the performance and reporting of autopsies and death certificates that were identified during the course of the original review.

METHODS

We studied cases that were adjudicated within state court systems, where most malpractice cases are tried. We relied on the appellate court summary of the medical record and the critical elements in the trial record on which the claims and counterclaims of the litigants were based. The written opinions of an appellate court typically contain a summary of the legal history, medical history, the basis for the claim, the legal issues on which the appeal is founded, a discussion of how legal precedents apply to the particular case, and conclude with a reasoned decision by the court.

AUTOPSY CONTROVERSIES

Controversial issues related to the autopsy per se, to the death certificate, or to both were common in the study group. Eighteen separate issues were raised, many of which were central to the resolution of the cases. The following selected examples are instructive.

Quality of the Autopsy

Outcome of a malpractice case may depend on the quality of the autopsy, specifically on the awareness of the pathologist of clinical issues, particularly those that are of potential medicolegal interest, and the thoroughness of the autopsy dissection with respect to those issues.

Example 1.-The autopsy pathologist found acute pulmonary embolism, but no source, in an adult who died a few days after surgical repair of an ankle fracture. Details of the extent of effort made at the time of autopsy to identify a source for pulmonary emboli were not available. The court ruled that a fracture cannot be established as the proximate cause of death in the absence of evidence that the emboli originated at the fracture site. In this case, the standard of care for treatment of a fracture was found to be acceptable. The defendant-physician was acquitted.

Comment.-With respect to a search for a source of pulmonary emboli, the standard of autopsy practice is not well defined and varies between institutions. The minimal acceptable approach is to search for a source within the confines of a conventional exposure of the viscera and probably should include massaging the contents of the femoral veins into the pelvis.

Example 2.-The autopsy pathologist found massive acute pulmonary embolism in an obese woman who died at home, a few hours after hospital discharge following a hysterectomy several weeks before. While in the hospital, she had developed deep calf vein thrombosis, was treated with dextran, developed chest pain 2 days before death, and was discharged after a normal chest radiograph was obtained. There was no information in the autopsy report that pertained to the question of whether the episode of chest pain 2 days prior to sudden death may have been caused by a previous episode of pulmonary embolism.